A nurse is caring for a client who has liver cirrhosis with ascites, bleeding esophageal varices, and portal hypertension. The nurse recognizes which of the following laboratory findings as indicating the client's gastrointestinal (GI) tract is digesting and absorbing blood?
Decreased bilirubin
Decreased chloride
Elevated blood urea nitrogen (BUN)
Elevated HbA1c
The Correct Answer is C
Rationale:
A. Decreased bilirubin is unrelated to digestion of blood in the GI tract.
B. Chloride levels do not indicate blood digestion.
C. When a client with esophageal varices bleeds into the GI tract, the digestion and absorption of blood proteins lead to increased nitrogen load, reflected as elevated BUN.
D. HbA1c reflects long-term blood glucose control, not acute digestion of blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Rationale:
- Potential Condition: The client developed new onset of severe, frequent diarrhea after receiving IV antibiotics (cefazolin), along with fever, abdominal cramping, dehydration (dry mucous membranes), and hyperactive bowel sounds. These are hallmark features of Clostridioides difficile colitis.
- Actions to Take:
- Contact precautions (gown and gloves) are essential to prevent transmission since C. difficile is highly contagious.
- IV fluids help correct dehydration and electrolyte losses caused by frequent diarrhea.
- Parameters to Monitor:
- Serum potassium should be monitored because diarrhea causes large potassium losses, risking hypokalemia.
- Blood pressure should be tracked closely since dehydration and electrolyte loss can lead to hypotension and hemodynamic instability.
Correct Answer is B
Explanation
Rationale:
A. Lactulose is usually administered orally to soften stools, not as a short-retention enema.
B. A Fleet enema is a hypertonic solution that draws fluid into the colon, is retained briefly, and promotes rapid evacuation of stool to relieve constipation.
C. Tap water enemas are hypotonic and typically require immediate expulsion, not short retention.
D. Mineral oil enemas are retention enemas, meant to soften stool over a longer period, not for rapid evacuation.
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